Primary care networks build on the core of current primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care. Clinicians describe this as a change from reactively providing appointments to proactively care for the people and communities they serve. Where emerging primary care networks are in place in parts of the country, there are clear benefits for patients and clinicians.
Primary care networks are based on GP registered lists, typically serving natural communities of around 30,000 to 50,000. They are small enough to provide the personal care valued by both patients and GPs, but large enough to have impact and economies of scale through better collaboration between practices and others in the local health and social care system.
7.13A.1.The Contractor must comply with the requirements in clause
7.13A.2 where it is:(a) signed up to the Network Contract Directed Enhanced Service Scheme (“the Scheme”); or(b) not signed up to the Scheme but its registered patientsor temporary residents, are provided with services under the Scheme (“the services”) by a contractor which is a member of a primary care network.
7.13A.2.The requirements referred to in clause 7.13A.1 are that the Contractor must:
(a) co-operate, in so far as is reasonable, with any person responsible for the provision of the services;
(b) comply in core hours with any reasonable request for information from such a person or from the Board relating to the provision of the services;
(c) have due regard to the guidance published by the Board;
(d) participate in primary care networkmeetings, in so far as is reasonable;
(e) take reasonable steps to provide information to its registered patients about the services, including information on how to access the servicesand any changes to them; and
(f) ensure that it has in place suitable arrangements to enable the sharing of data to support the delivery of the services, business administrationand analysis activities.
7.13A.3.For the purposes of this paragraph, “primary care network” means a network of contractors and other providers of services which has been approved by the Board, serving an identified geographical area with a minimum population of 30,000 people
service requirements in 2020/221
Requirements for the delivery of EHCHs by primary care networks (PCNs) are included in the 2020/21 Network Contact DES and associated guidance, with corresponding requirements for community health services and other NHS providers in the NHS Standard Contract. These requirements were fully implemented from 1 October 2020, including:
- every care home being aligned to a named PCN
- every care home having a named clinical lead
- a weekly ‘home round’ or ‘check in’ with residents prioritised for review based on MDT clinical judgement and care home advice (this is not intended to be a weekly review for all residents)
- within 7 days of re/admission to a care home, a resident will have a person-centred holistic health assessment of need (will include physical, psychological, functional, social and environmental needs of the person and can draw on existing assessments that have taken place outside of the home, as long as it reflects their goals)
- within 7 days of re/admission to a care home, a resident will have in place personalised care and support plan(s), based upon their holistic assessment
- the Network Contract DES also has a contractual requirement to prioritise care home residents who would benefit from a Structured Medication Review (SMR).
The Enhanced Health in Care Homes Framework has been updated to support the delivery of the minimum standards described in these contracts, and sets out practical guidance and best practice for CCGs, PCNs and other providers and stakeholders as they work collaboratively to develop a mature EHCH service, and should be read alongside these contractual requirements.
Structured medication reviews and medicines optomisation
Structured Medicine Reviews (SMRs) are an evidence-based and comprehensive review of a patient’s medication, taking into consideration all aspects of their health. In a structured medication review clinicians and patients work as equal partners to understand the balance between the benefits and risks of and alternatives of taking medicines. The shared decision-making conversation being led by the patient’s individual needs, preferences and circumstances.
Problematic polypharmacy is where, for an individual taking multiple medicines, the potential for harm outweighs any benefits from the medicines and/or they do not fully understand the implications of the medication regime they are taking. This includes:
- medicines that are no longer clinically indicated or appropriate or optimised for that person
- combination of multiple medicines has the potential to, or is actually causing harm to the person
- practicalities of using the medicines become unmanageable or are causing harm or distress.
SMRs have benefits to people taking multiple medicines:
- improved experience and quality of care through being involved in the decision-making process and having a better understanding of the medicines they take
- less risk of harm from medicines (e.g. adverse drug events, side effects, hospitalisation or addiction)
- better value for local health systems (e.g. reduced medicine waste).
Across England, general practices are working together with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas in primary care networks (PCNs). Professionals are working together to support patients with structured medication reviews as one of the PCN service requirements which commenced during 2020/21.
From October 2020, all PCNs are required to identify patients who would benefit from a SMR, specifically those:
- in care homes;
- with complex and problematic polypharmacy, specifically those on 10 or more medications;
- on medicines commonly associated with medication errors;
- with severe frailty, who are particularly isolated or housebound or who have had recent hospital admissions and/or falls;
- using potentially addictive pain management medication.
The number of patients to be offered a SMR will depend upon the PCN’s clinical pharmacist capacity. Further information on the expectations of PCNs and more detailed clinical guidance, for example from the Royal Pharmaceutical Society and NHS Scotland can be found in the Network Contract DES SMR guidance.
service requirements in 2021/22
From 1st Oct PCNs must confirm or exclude hypertension where blood pressure exceeds thresholds in GP and community settings, including reviewing patient records of previous elevated blood pressure. From 1st Oct PCNs must improve coverage of checks including opportunistic testing and aligning with the Community Pharmacy hypertension service.
From 1st Oct PCNs must identify and include all learning disability patients and patients with SMI on the respective registers and make reasonable efforts to deliver the set percentage of health checks. By 31st Dec PCNs and Commissioners must jointly identify a population experiencing inequality in provision/outcome and begin engagement. By 28th Feb PCNs must have a finalised plan to tackle this unmet need and proceed to deliver this from 1st March.
service requirements in 2022/23
In 2022/23 the CVD requirements expand to include atrial fibrillation, heart failure and familial hypercholesteremia, and requires quality improvement activity to support CVD prevention.
early cancer diagnosis
Service requirement 1: review referral practice for suspected and recurrent cancers, and work with their community of practice to identify and implement specific actions to improve referral practice, particularly among people from disadvantaged areas where early diagnosis rates are lower.
Service requirement 2: work with local system partners – including the NHS England and NHS Improvement Regional Public Health Commissioning team and Cancer Alliance – to agree the PCN’s contribution to local efforts to improve uptake in cervical and bowel NHS Cancer Screening Programmes and follow-up on non-responders to invitations. This must build on any existing actions across the PCN’s Core Network Practices and include at least one specific action to engage a group with low participation locally.
Service requirement 3a: work with its Core Network Practices to adopt and embed the requesting of FIT tests where appropriate for patients being referred for suspected colorectal cancer
Service requirement 3b: work with its Core Network Practices to adopt and embed where available and appropriate, the use of teledermatology to support skin cancer referrals (teledermatology is not mandatory for all referrals)
Service requirement 4: focusing on prostate cancer, and informed by data provided by the local Cancer Alliance, develop and implement a plan to increase the proactive and opportunistic assessment of patients for a potential cancer diagnosis in population cohorts where referral rates have not recovered to their pre-pandemic baseline.
Service requirement 5: review use of their non-specific symptoms pathways, identifying opportunities and taking appropriate actions to increase referral activity.
By 30 September 2022, a PCN must ensure all clinical staff complete the Personalised Care Institute’s 30-min e-learning refresher training for Shared Decision Making (SDM) conversations.
By 30 September 2022, as part of a broader social prescribing service, a PCN and commissioner must jointly work with stakeholders including local authority commissioners, VCSE partners and local clinical leaders, to design, agree and put in place a targeted programme to proactively offer and improve access to social prescribing to an identified cohort with unmet needs. This plan must take into account views of people with lived experience.
From 1 October 2022, commence delivery of the proactive social prescribing service for the identified cohort.
By 31 March 2023, a PCN must audit a sample of their Patients’ current experiences of shared decision making through use of a validated tool and must document their consideration and implementation of any improvements to SDM conversations made as a result.
By 31 March 2023 review cohort definition and extend the offer of proactive social prescribing based on an assessment of the population health needs and PCN capacity.
From April 2022 PCNs will deliver a single, combined extended access offer funded through the PCN DES. Further detail to be published this autumn.